Laserfiche WebLink
``SAN JOAQUIN�LOCAL HEALTH DISTRICT <br />: EOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '-466-6781 <br /> APPLICATION FOR WELL CONSTRUCT ON'•;QR PUMP PERMIT Permit No. <br /> THI§. PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date �Isstied -r-? <br /> h <br /> (Complete-In Triplicate) 0(S- 1-5'0 � <br /> Application is hereby made -to�the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health' District. <br /> JOB ADDPSSS/LOCATION)+001 Southr 1 � US TRACT � <br /> ' . C Gr'h <br /> Owner's Name J. ZeWalleriPhone <br /> F <br /> Address 871+2 NClements RdLi d City <br /> Contractor's Name Purviance Drillers _ � _ License # !±0102 Phone ' 887-35 1± <br /> TYPE OF=WORK_(Check) : NEW WELL �� DEEPEN / / RECONDITION /_�` NESTffleltTION <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X -- Cable Tool D`ia. of Well Excavation 1b <br /> Domestic/private Drilled Dia. of Well Casing 161, lG irn <br /> Domestic/public Driven Gauge of Casing= mate Irrigation-,-- Gravel. Pack_.___.Dep th-of-Gro-ut-Sea. 1 <br /> Cathodic Protection .'. - Rotary Type of-Grouti <br /> Disposal 'i. Other Other Information <br /> Geophysical Surface Seal Installed-BY: <br /> r. 1 <br /> PUMP INSTALLATION: \ Contractor <br /> Type of Pump € "' H.P. (" <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to -comply with-'all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well.construction. Within FIFTEEN DAYS" <br /> after completion of my work .on .a new well, I will furnish the San Joaquin Local Health District a, <br /> WELL DRILLERS REPORT of the well and notify them beforeputting the..well in use. The above <br /> information is true to -the best, of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO_GROUTI;IGL= A FINAL INSPECTION. <br /> TITLE artener <br /> SIGNED < <br /> ' DRAW PIT PLAN ON RE ERSE SIDE) <br /> a <br /> FOR DE ARTMENT USE ONLY [ <br /> PHASE I 1-7APPLICATION ACCEPTED.BY DATE <br /> ADDITIONAL COMMENTS: z ' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE,+ INSPECTION BY DATE <br /> 3/76 2M � <br /> E H 1426 Rev. '1-74: <br />